Provider Demographics
NPI:1336753094
Name:EMERSON, AMANDA M (DNP)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:M
Last Name:EMERSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 S JOHN RODES BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3336
Mailing Address - Country:US
Mailing Address - Phone:321-280-2080
Mailing Address - Fax:321-320-8820
Practice Address - Street 1:1540 S JOHN RODES BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3336
Practice Address - Country:US
Practice Address - Phone:321-280-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11015106363LA2100X
FL11015106363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114285200Medicaid
FLPB939OtherHF MEDICARE
FL114285200Medicaid